You can appeal a Medicare coverage decision through its appeal process. You must explain why you disagree with Medicare’s decision and provide supporting evidence from a doctor.

Sometimes, Medicare might deny coverage for an item, service, or test. You have the right to formally disagree with this decision and request Medicare reconsider the claim.

This process is called a Medicare appeal.

You can submit an appeal form and explain why you disagree with Medicare’s coverage decision.

Medicare will review your appeal and make a new determination. You’ll receive a notice when Medicare makes any decisions about your coverage.

As a Medicare beneficiary, you have certain protected rights that ensure access to the healthcare you need.

One is the right to take action if you disagree with Medicare’s coverage decision. This is called an appeal, and you can use it for claim decisions under all Medicare parts, including:

You can use an appeal in various situations, such as denial of coverage for a test or service.

Documents you’ll need for a Medicare appeal

You must gather documented evidence from your doctor, healthcare professional, hospital, or clinic that supports your appeal.

You’ll send this to Medicare along with your appeal form.

The 5 Medicare appeal levels

The appeals process has five levels. Each level has a different review process and timetable. You’ll need to request an appeal at each level if Medicare continues to deny a claim.

If your appeal is successful at the first level or you agree with Medicare’s reasoning for denying your appeal, you can stop there. However, if you still don’t agree with the decision, you can move to the next level.

You can file an appeal if Medicare has made a coverage decision that you think is in error. If your appeal is successful, Medicare will reverse or amend the decision.

Times when you can appeal include situations when:

  • Medicare denied prior authorization for an item, service, or prescription you think should be covered.
  • Medicare denied coverage for an item, service, or prescription you’ve already received and think should be covered.
  • Medicare charged you more for a covered item, service, or prescription than you think is accurate.
  • Your plan stopped paying for an item, service, or prescription you think is still necessary.

Why would Medicare deny coverage?

There are a few reasons Medicare might deny your coverage, including:

  • Your item, service, or prescription isn’t medically necessary.
  • You don’t meet the eligibility requirements to receive the item, service, or prescription.
  • Medicare never covers the item, service, or prescription, so claim denial decisions are usually final.
  • Medicare prefers you use a generic alternative or another medication in the same drug class that might be more cost-effective.

However, if you think your item, service, or test is medically necessary or that you do meet the requirements, you can appeal. Your appeal will include why you think Medicare has made the wrong coverage decision.

Example 1

Let’s say you were receiving physical therapy and got a notice saying Medicare would no longer cover it. In this situation, Medicare might have concluded that your physical therapy was no longer medically necessary.

If you and your doctor believe you still need physical therapy, you can have your doctor verify medical necessity. You’d provide this document when you file the appeal.

Example 2

There are some tests, screenings, and preventive care that Medicare will cover at 100% when you meet certain requirements.

Let’s say you got your annual flu shot, which is typically fully covered. You later received a bill for the 20% Part B coinsurance amount. You could appeal the 20% coinsurance charge. You’d need to prove that you met the requirements for the vaccine that ensured 100% coverage.

Medicare will let you know in writing if it has denied your coverage. The notice you’ll receive will let you know the steps you can take to file an appeal.

You have 120 days from the time you receive your initial claim determination to file an appeal.

Fast appeals

Sometimes, you’ll file what’s called a fast appeal. Fast appeals apply when Medicare notifies you that you will no longer receive cover for care at a:

You can appeal this notice if you think you’re being discharged too soon.

Your notice will tell you how to contact your state’s Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). The BFCC-QIO will notify the facility of your appeal and review your case.

In the case of a hospital, the BFCC-QIO will have 72 hours to make its decision. A hospital can’t discharge you while the BFCC-QIO is reviewing your case.

If you are in a nursing facility or another inpatient care setting, you’ll receive a notice at least 2 days before your coverage ends. The BFCC-QIO will need to make its decision by the end of the business day before you’re due to be discharged.

For all other appeals, you’ll need to follow the standard appeals process.

You’ve received an official notice

There are a few different notices you might receive from Medicare that would set off an appeal. Some common notices include:

  • Advance Beneficiary Notice of Noncoverage (ABN). An ABN lets you know that Medicare will not or no longer cover an item, service, or prescription.
  • Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). An SNF ABN lets you know that Medicare will no longer cover your stay in a skilled nursing facility. You’ll always get this notice at least 2 days before your coverage ends.
  • Fee-for-Service Advance Beneficiary Notice. This notice lets you know that Medicare will charge you for a service you have received or will be receiving.
  • Notice of Exclusion from Medicare Benefits. This notice informs you that Medicare does not cover a particular service.
  • Notice of Denial of Medical Coverage (Integrated Denial Notice). This notice tells you that Medicare will not cover all or part of a service. Medicare Advantage plans use this notice .
  • Hospital-Issued Notice of Noncoverage (HINN). A HINN lets you know that Medicare will no longer cover your hospital stay.
  • Notice of Medicare Noncoverage. This notice informs you that Medicare will no longer cover your inpatient care at a skilled nursing facility, rehabilitation facility, hospice, or home care agency.
  • Medicare summary notice. This shows you all your recent Medicare bills and claims. It will show you what Medicare paid and what you paid for any services you received.

Initiating an appeal

You’ll need to appeal within 120 days of receiving notice for the noncovered service. The notice you receive will let you know what form you need to fill out and the address to which you should send it.

Generally, you’ll fill out a:

No matter which form you complete, you’ll need to include specific information about your claim, including:

  • your name
  • your Medicare number
  • what noncovered item or service you’re appealing
  • information about why you believe Medicare should cover the service
  • any evidence you have to support your claim

You can also send a letter to Medicare with this same information. Your doctor, healthcare professional, clinic, or facility should be able to help you collect supporting evidence. This might include things like:

  • test results
  • diagnoses
  • certifications

Be sure to write your name and Medicare number on all the information you send. You should receive a response within 60 days after sending your appeal request.

Levels of appeal

There are five levels of the Medicare appeal process.

The first level is called redetermination and is your initial appeal step. The Medicare administrative contractor handles redetermination. They’ll review all the information you’ve sent and determine whether to cover your item, service, or prescription.

You can stop the process at level 1 if you’re happy with or understand the decision. If you still disagree with Medicare’s decision, you can keep going. The other levels are:

  • Reconsideration. At level 2, a qualified independent contractor reviews your appeal. You’ll need to fill out a request for reconsideration and include a detailed description of why you disagree with the decision made at level 1. You’ll receive the decision within 60 days.
  • Filing an appeal with the administrative law judge (ALJ). At level 3, you’ll have the chance to present your case to a judge. You’ll need to fill out a request form detailing why you disagree with your level 2 decision. Your appeal will only be elevated to level 3 if it reaches a set dollar amount.
  • Office of Medicare Hearings and Appeals review. The appeals board will review the ALJ decision made at level 3. You can request this by filling out a form and sending it to the board. If the board doesn’t hear your case within 90 days, you can move to level 5.
  • Federal court (judicial). The claim must be over a specific amount in order for the federal court to reconsider the appeal. In 2025, this amount is $1,900. This is the final appeal level.

Separate from a claim or coverage decision appeal, you can also appeal decisions that affect your monthly premiums.

This may include any late enrollment penalties Medicare charged you when you signed up for Part B or Part D.

Medicare charges a late enrollment penalty if you don’t sign up for Part B or Part D when you’re first eligible or if you lack similar adequate coverage.

You can appeal if you had coverage from another source, like an employer health plan, but you still received a late penalty charge.

You’ll need to prove you had comparable coverage to Medicare Part B or Part D to avoid these penalties.

IRMAA appeals

An income-related monthly adjustment amount (IRMAA) may affect your Part B or Part D premiums if you earn more than a specified amount.

IRMAAs are additional surcharges you’ll pay on top of your Part B or Part D premiums. They’re assigned based on your income and resources, as reported on your tax return from 2 years ago.

An Initial IRMAA determination lets you know the amount you’ll need to pay based on your income or resources, in addition to your Part B and Part D monthly premiums.

You can contact the Social Security Administration (SSA) directly to appeal an IRMAA if you think it didn’t assess your income accurately.

How do I file a grievance?

A grievance is a formal Medicare complaint about a plan or Medicare service in general. It does not impact the outcome of an appeal.

You have the right to appeal decisions Medicare makes about your coverage. You’ll need to provide proof that Medicare should cover your noncovered item, service, or test or that a penalty is incorrect.

You can get a fast appeal if Medicare stops covering your stay in a hospital, skilled nursing facility, or other inpatient setting.

You’ll hear an initial decision about your appeal within 60 days.